This article discusses the limited quantities of data concerning long-term durability of first-line ART regimens and time to transition to second-line among pediatric populations. Through a pediatric cohort study, this study team found that high rates of first-line failure and attrition were identified in children within 5 years after ART initiation. Of children meeting failure criteria, only one-third were transitioned to second-line ART within 5 years.